Clin Orthop Relat Res (2011) 469:2512–2520
DOI 10.1007/s11999-010-1695-8
SYMPOSIUM: REVERSE TOTAL SHOULDER ARTHROPLASTY
Scapular Notching in Reverse Shoulder Arthroplasty:
Is It Important to Avoid It and How?
Christophe Lévigne MD, Jérome Garret MD,
Pascal Boileau MD, Ghassan Alami MD,
Luc Favard MD, Gilles Walch MD
Published online: 30 November 2010
Ó The Association of Bone and Joint Surgeons1 2010
Abstract
Background Scapular notching, erosion of the scapular
neck related to impingement by the medial rim of the
humeral cup during adduction, is a radiographic sign spe-
cific to reverse shoulder arthroplasty (RSA). Its clinical and
radiological consequences remain unclear.
Questions/purposes Therefore, we: (1) determined the
incidence of notching in a large series, (2) described the
natural history of notching, (3) determined whether
notching is related to functional scores or (4) radiographic
signs of failure, and (5) identified factors related to notch
development.
Patients and Methods We retrospectively reviewed
448 patients who underwent a Grammont-type RSA
(461 shoulders) with a mean followup of 51 months (range,
Four authors (CL, PB, LF, GW) certify that they have commercial
associations (royalties) that might pose a conflict of interest in
connection with the submitted article.
Each author certifies that his institution approved the human protocol
for this investigation and that all investigations were conducted in
conformity with ethical principles of research.
This work was performed at the Clinique du parc Lyon France, the
Hôpital de l’Archet Nice France, the Centre Hospitalier de Tours
France, and the Centre Orthopédique Santy Lyon France.
C. Lévigne (&), J. Garret
Clinique du parc, 155 ter Bd Stalingrad, 69006 Lyon, France
e-mail: c.levigne@cliniqueduparclyon.fr
P. Boileau, G. Alami
Hôpital de l’Archet, Nice, France
L. Favard
Centre Hospitalier de Tours, Tours, France
G. Walch
Centre Orthopédique Santy, Lyon, France
123
24–206 months). RSA was implanted for cuff tear
arthropathy or osteoarthritis with cuff deficiency. We
assessed scapular notching using AP views standardized
under fluoroscopy. Clinical assessment included Constant-
Murley score and range of motion. Aside from notching,
radiographic assessment included evaluation of humeral
and glenoid radiolucent lines.
Results Notching occurred in 68% of cases. It appeared
early, but its later evolution was variable. Notching was
associated with followup, strength, passive and active
elevation, humeral radiolucent lines, and glenoid lucent
lines. It also correlated with a higher rate in patients with
preoperative superior erosion.
Conclusions Scapular notching is frequent, generally
progresses, and is associated with deterioration of some
clinical parameters and radiolucent lines. We believe the
preoperative pattern of glenoid erosion is of particular
importance due to its influence on the surgeon’s glenoid
preparation and base-plate positioning. It is crucial to avoid
cranial position and superior tilt.
Levels of Evidence Level IV, Therapeutic study. See
Guidelines for Authors for a complete description of levels
of evidence.
Introduction
Notching of the scapular pillar is a radiographic observa-
tion specific to reverse shoulder arthroplasty (Fig. 1).
Grammont and Baulot [1, 9] initiated the concept and
realization of semiconstrained reversed prosthesis, but did
not report on notching. First described by Sirveaux in 1997
[17], and later by De Wilde et al. [6], this phenomenon is
an osseous defect in the scapular neck caused by the
impingement of the medial border of the humeral
Volume 469, Number 9, September 2011
Fig. 1 A radiograph shows a large scapular notch reaching the
glenoid base plate’s inferior screw.
prosthetic cup against the superior part of the scapular
pillar when the arm is adducted. Nyffeler et al. [14] sug-
gested an osteolytic reaction associated with polyethylene
(PE) wear debris contributing to scapular notch progres-
sion. Moreover, it is reportedly related to eventual glenoid
component loosening [4, 18–20]. However, the evolution
of scapular notching is unclear, clinical and radiographic
consequences are controversial, and causal factors are
unknown.
The purposes of our study were to: (1) determine the
incidence of notching in a large series; (2) describe the
natural history of notching; (3) determine whether notching
is related to functional scores and (4) radiographic signs of
failure; (5) identify factors related to notch development;
(6) deduce technical recommendations to avoid it.
Patients and Methods
This is a retrospective and multicenter study of 506 patients
(527 shoulders) operated on between 1987 and 2003 at ten
different centers for a Grammont-type reversed prosthesis
with a minimum of 2 years of followup. We excluded
38 patients (43 shoulders): 10 patients (12 shoulders) died
of causes unrelated to the surgery before the minimum
followup, four (5 shoulders) were lost to followup, and
24 (26 shoulders) had prosthesis removal before 2 years of
followup. We also excluded 20 additional patients
(23 shoulders) due to inadequate radiographic views for an
accurate evaluation of the scapular notch. These exclusions
left 448 patients (461 shoulders). The patients’ mean age
was 73 years (range, 40–90 years) and gender ratio was
24% men and 76% women. Indications were cuff tear
arthropathy in 92% of cases and osteoarthritis with cuff
Scapular Notching in Reverse Arthroplasty 2513
Fig. 2 An image describes Favard et al.’s [7] classification of the
different types of glenoid erosion – E0: superior humeral migration
with no glenoid erosion; E1: concentric glenoid erosion; E2: glenoid
erosion predominantly in the superior pole; E3: global glenoid erosion
more severe in the superior pole; E4: glenoid erosion predominantly
in the inferior pole.
deficiency in 8% of cases. The minimum followup was
24 months (mean, 51 months; range, 24–206 months).
We classified glenoid erosion on the AP view using the
method of Favard et al. [7] (Fig. 2): E0 for superior
humeral head migration without erosion of the glenoid
(53% of the series), E1 for concentric erosion of the
glenoid (17%), E2 for erosion limited to the superior part
of the glenoid (12%), E3 for erosion extending to the
inferior part of the glenoid (15%), and E4 for erosion
predominantly located at the inferior part of the glenoid
(3%). We graded the severity of fatty infiltration on CT or
MR images using the classification of Goutallier et al. [8]:
Grade 1 for fat traces in muscle (8% of the series), Grade 2
for less fat than muscle (11%), Grade 3 for similar amount
of fat and muscle (18%), Grade 4 for more fat than muscle
(62%).
We implanted the prosthesis via a superolateral
approach in 45% cases and through a deltopectoral
approach in 55% cases. We used the Delta reverse pros-
thesisTM (DePuy International Ltd, Leeds, England) in 87%
of cases and, after October 2002, the Aequalis Reverse
ProsthesisTM (Tornier, Houston T, USA) in 13% of cases.
Both models were designed according to Grammont rec-
ommendation with a 155° inclination angle. Two diameters
of glenosphere and humeral cup were available in both
models: we used 36 mm in 85% of cases and used 42 mm
in 15% of cases.
Passive rehabilitation began the day after surgery in
98% of cases and was supervised by the physiotherapist,
whereas ten shoulders (2%) were temporarily immobilized
without rehabilitation. We used a regular sling with the arm
adducted in 83% of cases and an abduction brace in 17%.
The arm was free after an average of 6 weeks.
For purposes of the study, we contacted all patients for
clinical and radiographic assessments to obtain maximal
followup. Clinical evaluation included the absolute and
age/gender-related weighted Constant-Murley scores [5]
and active and passive range of motion. We recorded
strength in external and internal rotation, as well as sub-
jective ratings.
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2514 Lévigne et al.
Fig. 3 A drawing shows classification of scapular notching according
to Sirveaux et al. [18]. Grade 1 shows a notch limited to the scapular
pillar, Grade 2 shows a notch reaching the inferior screw of the base
plate, Grade 3 shows a notch extending beyond the inferior screw, and
Grade 4 shows a notch reaching the base-plate’s central peg.
Radiographic evaluation included true AP and axillary
views. When available, we assessed radiographs at
6 weeks, 1 year, 2 years, and 3 years postoperatively to
evaluate notch formation and early progression. According
to standard protocol, we used fluoroscopic control to ensure
that the flat side of the hemispheric glenoid implant
appeared flat on the AP view. Inclination of the beam in the
sagittal plane was not standardized. We analyzed the
scapular notch on the AP view according to the classifi-
cation of Sirveaux et al. [17]: Grade 1 for a notch limited to
the scapular pillar, Grade 2 for a notch reaching the inferior
screw of the base plate, Grade 3 for a notch extending
beyond the inferior screw, and Grade 4 for a notch reaching
the base-plate’s central peg (Fig. 3). We also analyzed it
using the axillary view and recorded pillar spurs and/or
ossification in the scapulohumeral space. Regarding the
glenoid component, we assessed radiolucencies under the
baseplate and around the central peg and fixation screws
and recorded humeral radiolucencies in seven different
zones (Fig. 4).
Final radiographs beyond 2 year followup were avail-
able for 461 patients. Interval radiographs were available
for 231 patients at 1 year followup, for 239 at 2 year fol-
lowup, and for 254 at 3 year followup. Each center
evaluated their radiographs for notching and one of us (CL)
checked all radiographs. Radiographic followup averaged
51 months (range, 24–206 months). One-hundred-fifty-two
shoulders (33%) had a followup greater than 60 months,
138 (30%) had a followup between 36 and 60 months, and
171 (37%) had a followup between 24 and 36 months.
Concerning statistical analysis, we tested all clinical and
radiological variables in three different ways, according to
the definition of the notch. For the first method, we com-
pared cases with and without notching, regardless of grade,
and determined differences in variables with the Mann-
Whitney U test. For the second method, we compared cases
without notching versus notching Grades 1 to 2 and versus
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Clinical Orthopaedics and Related Research1
Fig. 4 A drawing depicts the zones of radiolucent lines around the
humeral implant.
notching Grades 3 to 4 and used the Kruskal-Wallis test to
determine differences in variables. As for the third method,
we compared cases without notching and the four grades of
notching independently. Software used was StatView (SAS
Institute, Cary, NC, USA).
Results
At last followup, we observed scapular notching on the AP
view of 312 of the 461 cases (68%). We recorded 22% as
Grade 1 notches, 23% as Grade 2, 13% as Grade 3, and
10% as Grade 4.
Notching tended to appear early. We found notching in
48% of cases at 1 year postoperatively, 60% at 2 years, and
68% at 3 years. The incidence increased (p \ 0.001) with
followup (Fig. 5).
Notch evolution varied from case to case; some notches
stabilized rapidly after their appearance, while others grew
progressively over a long period of time. We observed
three groups of patients: those who never developed
scapular notches, those with notches that stabilized within
2 years, and those with notches that continue to progress
beyond 3 years. We observed an increase (p \ 0.001) in
the number of Grade 3 and Grade 4 notches, with longer
postoperative followup owing to the third group that pro-
gressed. At last followup, 22% of Grade 3 or Grade 4
notches were one grade less severe at 3 years
postoperatively.
Volume 469, Number 9, September 2011
Fig. 5 A graph shows the notch incidence as a function of
postoperative followup.
Activity level influenced the rate of notch development;
more active patients had higher (p = 0.03) notch incidence
(74% compared with 64% for inactive patients). Notch
incidence varied (p = 0.01) with original diagnosis: 71%
for cuff tear arthropathy and 47% for osteoarthritis with
cuff deficiency. Notching also correlated with decreased
preoperative acromiohumeral distance (p \ 0.0001),
severity of fatty infiltration of the infraspinatus muscle
(68% for Grades 3 and 4, and 52% for Grades 0, 1, and 2,
p = 0.02), and, interestingly, the type of glenoid erosion.
The greatest (p = 0.004) difference appeared between
Type E2 glenoid superior erosion, associated with a notch
incidence of 83%, and Type E4 inferior glenoid erosion,
associated with a 25% notch incidence. There was a lower
(p = 0.001) notch incidence with a deltopectoral approach
than with a superolateral approach (56% versus 86%,
respectively). This may be debatable due to the different
followup lengths of the two approaches (43 months versus
59 months, respectively).
We found no relationship between scapular notching and
pain or Constant-Murley score. Strength was decreased by
a mean of 0.5 kg in cases with notching compared to cases
with no notch (p = 0.04). Also, we observed a decreased
(p = 0.01) passive and active anterior elevation in the
presence of a notch (141° and 128°, respectively), compared
to cases with no notch (147° and 134°, respectively).
We found an association (p \ 0.001) between notching
and a ‘‘pillar spur’’ (63% spur incidence with notching
versus 43% without). The incidence of humeral radiolucent
lines was higher (p = 0.001) in the presence of notching
(36% with notching versus 17% without), and greatest
(p \ 0.0001) in the proximal zones, particularly Zone 7,
closest to the notch (Fig. 4). Glenoid radiolucent lines were
more frequent (p = 0.03) in the presence of a notch than in
the absence (9% and 3%, respectively). If the comparison
concerns only notching of Grades 2, 3, and 4 versus no
notch, the difference is stronger (p \ 0.001): 13% and 3%,
respectively.
Scapular Notching in Reverse Arthroplasty 2515
Fig. 6 An imperfect anteroposterior radiograph shows how the
glenoid hemisphere is not viewed in profile and obscures the zone
of notching.
Discussion
Radiographically apparent scapular notching is specific to
reverse shoulder arthroplasty (RSA). Despite numerous
reports on the phenomenon, its clinical and radiological
consequences remain unclear. The purposes of our study
were therefore to: (1) determine the incidence of notching
in a large series, (2) describe the natural history of notch-
ing, (3) determine whether notching is related to functional
scores and (4) radiographic signs of failure, (5) identify
factors related to notch development, and (6) deduce
technical recommendations to avoid it.
Our study has a number of limitations. First, our mean
followup is relatively short (51 months), but 33% of cases
had a followup between 5 and 17 years. Second, it is a
retrospective and multicentre study, which implies a rela-
tive lack of standardized method of radiographic technique
and analysis. We attempted to reduce variability of radio-
graphic interpretations with systematic review of all the
radiographs by one of authors (CL). This eliminates
interobserver variability, but introduces the possibility of
systematic bias in interpretations. Third, evaluation of
notching requires precise patient positioning (Fig. 6) and
fluoroscopy for alignment of the X-ray beam with the flat
side of the baseplate (Fig. 7). In the sagittal plane, orien-
tation of the beam must be horizontal (not craniocaudal) to
accurately show notching, which is at the inferior pole of
the glenoid and, in some cases, posteroinferior, where the
scapular pillar arises (Fig. 8). This anatomic fact may
explain why, in some cases, the notch is better visualized in
the axillary view than the AP view (Fig. 9). A postmortem
analysis illustrates the variability of notching appearance
according to the orientation of the beam, the same case
being possibly graded notching 1 to 4 depending of the
position of the scapula (Fig. 10). The presence of a bony
spur medial to the notch may make the notch appear larger
(Fig. 11). Fourth, it is difficult to evaluate the size of the
notch. Several radiographic classifications have been
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2516 Lévigne et al.
Fig. 7A–B (A) Photo shows patient undergoing anteroposterior
radiograph of the shoulder. (B) The patient’s radiographs show the
procedure to attain the correct anteroposterior view. (1) The patient
stands naturally and turns toward the involved side until the glenoid
base plate appears perfectly flat (tangential) on the fluoroscopic
monitor, (2) the X-ray beam is oriented horizontally, and (3) the
image is taken during the expiration phase to minimize overlap
between the ribcage and the prosthesis.
Fig. 8 Photo of the profile view of a scapula shows the scapular
pillar’s posterior origin (arrow) in reference to the glenoid.
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Clinical Orthopaedics and Related Research1
Fig. 9A–B Radiograph indicating notching. (A) The notch is difficult
to see in the anteroposterior view due to the downward orientation of
the X-ray beam. (B) It is seen more easily on an axillary view (arrow).
proposed [2, 17, 19]. We used a four-grade classification
presented by Sirveaux [17] (Fig. 3). However, in light of
the above-mentioned difficulties, we now use a more
practical and realistic two-grade classification that regroups
Sirveaux Grades 1 and 2 into a single group and Grades 3
and 4 into another [12] (Fig. 12).
We found an incidence of notching in 68% of cases with
a mean followup of 51 months which is consistent with the
literature [3, 4, 7, 16, 18–21], which reported ranges of
50% to 96% at 31 to 84 months followup.
The frequency of scapular notching increased with fol-
lowup: we observed notching in 48% of shoulders at 1 year
postoperatively, 60% at 2 years, and it continued to
increase over time. We observed three groups of patients:
those who never developed scapular notches, those with
notches that stabilized within 2 years, and those with not-
ches that continued to progress beyond 3 years. This
explains the increase of the proportion of Sirveaux Grade 3
and 4 notches with longer postoperative followup. Vari-
ability of evolution is possibly related to the mechanism of
notch formation, depending on the respective participation
of the two major presumed causes: mechanical contact and/
or osteolytic reaction secondary to PE debris [2, 6, 10, 14].
We found no relationship between notching and pain or
the Constant-Murley score. However, our mean followup
was only 51 months and it is possible clinical symptoms
will appear with longer followup. Strength, as measured in
Volume 469, Number 9, September 2011
Fig. 10A–B Postmortem radiographs
explain RSA. The anatomic specimen
(A) shows a notch (arrow) exposing
partially the inferior screw (definition
of Grade 2), whereas a radiograph of
that specimen can give the false
impression that the notch does not
reach the screw (defined as Grade 1)
(B), or extends all the way to the base
plate’s central peg (definition of Grade
4) (C). (Illustration courtesy of L.
Favard.)
Fig. 11 This radiograph shows a bony spur adjacent to the zone of
notching.
Constant-Murley score, showed a mean diminution of
0.5 kg in the presence of notching. Glenoid radiolucent
lines were more frequent in the presence of a notch than in
its absence (9% and 3%, respectively). However, our data
provides no support for the suggestion of progressively
failing glenoid fixation due to notch progression, proposed
by several authors [15, 20]. The correlation between
notching and radiolucencies around the implants is cer-
tainly worrying for the future and a sufficient reason to
avoid it, even if there is no current clinical consequence.
Superior glenoid erosion (Type E2) is associated with a
high rate of notching, and we think it leads to superior
positioning of the base plate, which increases contact
between the medial edge of the humeral cup and the
inferior edge of the glenoid or the scapular pillar (Fig. 13).
We did not quantitatively demonstrate the importance of
this factor in this series, but we now measure the cranio-
caudal position of the glenoid component (Fig. 14). As
recommended by Nyffeler et al. [13], we strive to place the
inferior border of the base plate at the inferior edge of the
glenoid so the glenoid hemisphere overhangs it by 4 mm.
However, we think an inferiorly positioned base plate does
Scapular Notching in Reverse Arthroplasty 2517
not always prevent impingement with the inferior screw,
especially if the base plate is in valgus (superior tilt)
(Fig. 15). We suggest coronal inclination of the baseplate
is also a factor of notching that may be influenced by the
type of preoperative glenoid erosion. The surgeon’s natural
tendency is to prepare the glenoid in its native orientation.
When the glenoid is eroded superiorly the inclination is in
valgus (superior tilt), and the tendency is to position the
base plate with a similar orientation, allowing the humeral
cup to override the inferior glenoid hemisphere and contact
the scapular pillar (Fig. 16). Conversely, with inferior
glenoid erosion, the inclination is in varus (inferior tilt),
with a tendency to position the base plate likewise. There is
little or no overriding by the humeral cup medial to the
glenoid hemisphere, resulting in a lower risk of impinge-
ment and subsequent notching (Fig. 17). In order to
quantitatively demonstrate the incidence of baseplate
inclination in notching, we have tested, unsuccessfully,
different radiographic methods, including referring to the
scapular neck, proposed by Simovitch et al. [16]. We now
calculate baseplate inclination in reference to the hori-
zontal line in a standardized AP view, with patients
standing naturally with their arm at their side (Fig. 18)
[11]. This method is independent of any anatomic land-
marks on the scapula and integrates the tilt of the scapula
itself in the coronal plane (which varies greatly among
patients). An inclination angle that is greater than 90°
implies a varus position (inferior tilt), while an inclination
angle less than 90° implies a valgus position (superior tilt).
We adapted our glenoid reaming to the preoperative
glenoid inclination, evaluated in the same manner
described above on a preoperative standardized AP view. If
the preoperative inclination is neutral (vertical), we ream
uniformly without attempting to alter glenoid orientation.
If the preoperative inclination is in valgus, we ream the
inferior portion of the glenoid to reestablish neutral
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2518 Lévigne et al. Clinical Orthopaedics and Related Research1

Fig. 12 This image shows the two-grade SOFCOT classification [12]: Grade 1 representing a notch falling short of the inferior screw, and Grade
2 representing a notch reaching or extending beyond the inferior screw. Grade 0 signifies the absence of notching.

Fig. 13A–B These radiographs depict a scapular notch associated

with a glenoid component implanted too superiorly (B), which may
have been favored by predominantly superior preoperative glenoid
erosion (A).

Fig. 15 A radiograph shows a glenoid component implanted in an

inferior position but with superior tilt; the inferior screw is beneath
the scapular pillar and the superior screw is beneath the base of the
coracoid. Note the erosion of the inferior screw and the ‘‘kissing
lesion’’ on the medial edge of the metallic humeral implant.

Fig. 14 A radiograph shows the method of measuring glenoid

component height in reference to the inferior glenoid rim.
inclination. In so doing, it is essential to combine inferior
translation to avoid leaving an inferior bony ridge. We
agree with Werner et al. [21] that this method slightly
Fig. 16A–B These radiographs show that when the glenoid erosion is
superior, its overall coronal inclination is in valgus (A), and the
surgeon’s tendency is to position the base plate also in valgus (B),
increasing the humeral cup’s overriding of the inferior glenoid
hemisphere during adduction and, perhaps, increasing the risk of
notching.

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Volume 469, Number 9, September 2011
Fig. 17A–B Radiographs show that when the glenoid erosion is
inferior, its overall coronal inclination is in varus (A), and the
surgeon’s tendency is to position the base plate also in varus (B),
reducing the extent the humeral cup can override the inferior glenoid
hemisphere and, perhaps, decreasing the risk of notching.
Fig. 18 A radiograph shows the method of measuring glenoid-
implant inclination using the angle formed by the line parallel to the
glenoid base plate and the horizontal. An angle greater than 90°
indicates a glenoid in varus (inferior tilt) while an angle less than 90°
indicates a glenoid in valgus (superior tilt).
affects the inferior bone stock of the glenoid, but believe
this is an acceptable trade-off to help avoid scapular
notching in the future.
In summary, at a mean followup of 4 years, we found
scapular notching increased in incidence and severity and
was accompanied by decreases in strength and anterior
elevation. It was also associated with an increased inci-
dence in humeral and glenoid radiolucent lines. Therefore,
it is essential to do everything possible to prevent this
phenomenon. Of all the associated factors discussed above,
the type of preoperative glenoid erosion seems to be
Scapular Notching in Reverse Arthroplasty 2519
especially influential, likely through its effect on the base
plate’s final position. Nyffeler et al. [13] demonstrated the
preventive effect of positioning the baseplate flush with the
inferior glenoid edge, and we advocate the avoidance of a
superiorly tilted base plate.
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